Crimson Publishers
Wings to the Research
ISSN: 2690-9707
*Corresponding author: Jose Luis
Turabian, Specialist in Family and
Community Medicine, Health Center
Santa Maria de Benquerencia Toledo,
Spain
Submission: February 13, 2023
Published: March 15, 2023
Volume 2 - Issue 3
How to cite this article: Jose Luis
Turabian*. Strategic Diagnosis and
Treatment in General Medicine. Associative
J Health Sci. 2(3). AJHS. 000540. 2023.
DOI: 10.31031/AJHS.2023.02.000540
Copyright@ Jose Luis Turabian, This
article is distributed under the terms of
the Creative Commons Attribution 4.0
International License, which permits
unrestricted use and redistribution
provided that the original author and
source are credited.
Associative Journal of Health Sciences
Mini Review
Strategic Diagnosis and Treatment in
General Medicine
Jose Luis Turabian*
Specialist in Family and Community Medicine, Health Center Santa Maria de Benquerencia, Regional
Health Service of Castilla la Mancha (SESCAM), Toledo, Spain
Abstract
At present, medicine seeks to achieve decisions based on evidence (Evidence-Based Medicine) and in
precision medicine. But, in general medicine, the diagnosis is not the act of redirecting the individual
case to a “type”, among those included in a classification system, nor is this sufficient for personalized
treatment. The answer about multiple complex health problems in an individual cannot be answered by
adding separate questions; neither are biomarkers available for use in ordinary clinical practice. How
can we deal with this situation? with strategic contextualization? It is about finding a global response,
a global characterization of the individual case beyond diagnosis. The process of making diagnoses
and treatments in general medicine begins to look at the main forces or actors. It’s like the motive in a
detective story. It is about finding the significant event that never ceases to occur. It is about finding the
element that moves the system. The question is to detect it and take advantage of it. Strategic diagnosis
and treatment is directed towards the context. Environment constitutes the criteria for making decisions.
Introduction
Diagnosis (i.e., the act of redirecting the individual case to a “type”, among those included
in a classification system) is in itself insufficient to guide the formulation of a personalized
management plan and a reliable prognosis in general medicine (GM) [1]. While in many
medical specialties the diagnosis brings with it a quantity of information that also points to a
given etiology and/or pathogenesis, and thus significantly informs the choice of therapeutic
intervention. The amount of information that the diagnosis brings with it in GM is somewhat
lower [2,3]. In fact, both research evidence and clinical experience tell us that patients who
share the same diagnosis often respond differently to a given treatment, while patients with
different diagnoses may respond similarly to a given treatment.
At present, medicine seeks to achieve decisions based on evidence (Evidence-Based
Medicine-EBM) and “precision medicine” [4]. But, on the one hand, it has become clear that
identifying and synthesizing all the scientific studies that answer a question constitutes
an insurmountable challenge for a clinician due to the dizzying growth in the amount of
information. And besides, is it answering a question. But, since the complex patient raises
many questions at the same time (What is the best treatment for a 46-year-old patient with
angina, poorly controlled arterial hypertension, left ventricular hypertrophy, heart failure,
diastolic disease, type 2 diabetes mellitus, diabetic nephropathy, dyslipidemia, obesity,
anxiety-depressive syndrome, alcoholic liver disease, alcohol abuse, smoker, with bronchial
asthma and chronic urticaria, with legal, economic, and family problems, who is religious,
who is non-compliant, who is a frequent consultant, with an occasionally hostile behaviour,
and who lives in a marginal area...?). The question cannot be answered by adding separate
questions. It is about finding a global response. And the presence of multiple diseases increases
the uncertainty about the benefits and harms of directly applying a clinical guideline, since
most trials exclude patients with multiple diseases [5]. And on the other hand, in “precision
medicine”, it is intended that biological markers have an important role. In GM, we do not have
biomarkers ready for use in ordinary clinical practice, but we need even more, for the reasons
we have just seen, an additional or global characterization of the individual case beyond
diagnosis. How can we deal with this situation?: with strategic contextualization.
1
 AJHS.000540. 2(3).2023
In the time of the pharaohs, there was an important temple in
Egypt located behind the Nubian Falls, in what is now the desert of
northern Sudan. Three rivers join in that region to form the Nile,
achieving the annual miracle of its flooding that allows farmers
to grow grain in the extremely dry climate. Every spring, the high
priest of the temple would go to the bridge over the Nile to observe
the colour of the water. If it was clear, it was the White Nile, flowing
from Lake Victoria through the swamps of the Sudan that would
dominate the channel. The flood would be light and late; farmers
would produce a minimal grain crop. If the river appeared dark,
the strong currents of the Blue Nile, which joined the White Nile at
Khartoum, would prevail. The flood would be enough to saturate the
fields and provide a good harvest. Finally, if the river waters were
predominantly greenish brown, they came from the Atbara, flowing
rapidly from the Ethiopian highlands, and then there would be very
rapid and catastrophically intense flooding would be drowned; The
Pharaoh should keep wheat in reserve. Every year the priest sent
messengers to Pharaoh to inform him of the colour of the waters.
Thus, he knew how prosperous the peasants of his kingdom would
be, and how much he could raise taxes, so that he would know if he
could afford to start the conquest of other territories.
The process of making diagnoses and treatments in GM begins
in the same way as the priest did, looking at the main forces or
actors, for what are the key forces and actors relationships that
influence the outcomes of events. These key elements (with energy)
determine the argument and result of the patient’s health/disease
history. It’s like the motive in a detective story. In fact, the task of
the general practitioner (GP) is like that of the detective, searching
for the hidden forces that clarify the inexplicable murder. Without
key forces, diagnosis and treatment cannot be thought of. Finding
these key elements early is critical to decision making, and we
can leave other lesser forces out of our focus. The GP has to have
a plan. It is not about waiting for an inspiration; it is about finding
the significant event that never ceases to occur. The question is to
detect it and take advantage of it.
The key forces of a patient’s health/disease scenario may be
obvious to one person and hidden from another, so it is better to build
diagnoses and treatments as a team (after doing the investigative
work individually): doctor, patient, family, other actors, nurse, social
worker, specialists, pharmacist, healer… The aviation industry has
developed, but only after many small forces converged-engine
research, air traffic control development, government support for
airports, etc. Cars cannot truly function without paved roads, gas
stations, tires, rubber industries, car design, assembly lines, and
the vast network of highways and streets. If someone wants to
make major changes to automobiles (like design electric cars, or
cars that run on rails), they can’t just design a machine. You have to
think about changing the network of systems that support the car.
Associative J Health Sci
2
Similarly, to plan the intervention on a patient, the context (family,
group, community systems) that surrounds him must be included.
Strategic diagnosis and treatment is directed towards the
context. The environment constitutes the criteria for making
decisions; seeks competitive advantage, diversifications,
opportunities, advantages and threats. When a strategy is built, it is
not intended to make decisions about the future at the moment, but
to make decisions taking the future into account. Strategy is not an
end in itself, but only a means. It must be constantly reassessed and
readjusted based on changes [6].
The GP today needs a systematic guide, which current
diagnostic systems and related tools do not provide or do not
provide satisfactorily, thus contributing to a therapeutic practice
that, guided only by diagnostic labels, is often over-simplified and
stereotyped [6].
The strategic contextual analysis allows seeing beyond the
knot of the complex question. It is aimed at knowing resources and
potential for the achievement of goals. It can make it possible to
overcome resistance to change and create favourable conditions
for medical intervention. Strategic questions when planning
the intervention include the following: who will be affected by
the physician’s intervention, who could stop the medical action,
who could facilitate implementation, what are the strengths and
weaknesses of the patient and his family? What are the interests of
the patient? Have the objectives of the medical intervention been
agreed upon with the main actors? The final stretch of a race is
the outcome of a drama outlined long before. Finding the element
defines the system. “Know your enemy and know yourself and in
100 battles you will never be defeated”.
References
1. Turabian JL, Perez Franco B (2010) The concept of treatment in family
medicine: A contextualised and contextual map of a city hardly seen.
Atent Primaria 42(5): 253-254.
2. Maj M (2018) Why the clinical utility of diagnostic categories in
psychiatry is intrinsically limited and how we can use new approaches
to complement them. World Psychiatry 17(2): 121-122.
3. Turabian JL (2017) Fables of family medicine. A collection of fables that
teach the principles of family medicine. Editorial Académica Española,
Saarbrücken, Germany.
4. National Research Council of the National Academies (2011) Toward
precision medicine. Building a knowledge network for biomedical
research and a new taxonomy of disease. National Academies Press,
Washington, USA.
5. Turabian JL, Perez Franco B (2014) Album of models for qualitative
tools in the Family Medicine decision making. Other maps to describe a
country. Semergen, Madrid, Spain 40(8): 415-424.
6. Mcneilly M (2011) Sun Tzu and the art of business. Six strategic
principles for managers. Revised Edition. Oxford University Press.
Copyright © Jose Luis Turabian